PPO Medical Policies*

Although your Benefit Booklet provides a good overview of what services and products are available to you under the PPO plans, the medical policies provide detailed information around the circumstances under which certain services and products are and are not covered. Behavioral health and prescription policies are listed below. All other medical policies can be found here on the Blue Cross Blue Shield Web site*. Please check both areas for more information.

In addition, you can find a list of upcoming medical policy changes by clicking here.

Medical Policy Name Number

Behavioral Health Policies
Crisis Evaluation and Stabilization Services IN0560
Electroconvulsive Therapy (ECT) IN0300
Inpatient Medical Detox for Chemical Dependency AD0420
Inpatient Psychiatric or Chemical Dependency Care IN0450
Mental Health/Chemical Dependency Case Management AD0430
Outpatient Psychotherapy ME0650
Outpatient Treatment in Intensive Outpatient Program ME0495
Partial Hospitalization IN0550
Psychological Testing AH0725
Residential Treatment for Adolescent Psychiatric Care IN0510
Residential Treatment for Chemical Dependency IN0520

Prescription Policies
Prescription Policies AD0528
* If any of the State Health Plan medical policies conflict with the Blue Cross and Blue Shield of North Carolina medical policies, the State Health Plan medical policies will prevail.